05/02/08

To inform or to (over)protect? The Swiss have chosen well

I’ve been taken to task for not weighing in on the kerfuffle about whether people on ARVs can pass on HIV. In case you haven’t been following the debate, the Swiss AIDS Commission has reviewed studies of couples where one partner has HIV and the other doesn’t, and has looked at HIV transmission with and without antiretroviral treatment. They conclude that

1) IF a person takes their meds religiously
2) AND IF they are under medical observation
3) AND IF that observation shows their viral load has been undetectable (fewer than 40 viral copies per ml of blood) for six months continuously
4) AND IF they don’t have another sexually transmitted infection
THEN there’s no risk that they will pass on HIV in sex.

You can find the full paper in French here, and an unofficial English translation here. The key references: Quinn et al 2000, Castilla et al 2005, Melo et al 2006, Barreiro et al 2006.

Needless to say, there has been a lot of comment about this here, for example, and here, and here. For my money, the most sensible comment comes from Rex Wockner who points out, quite correctly, that the Swiss usually do their homework pretty thoroughly. So they’re probably right, but should that make anyone throw out the condoms with an untested partner? Of course not. Unless you have some preternatural way of telling that all the IFs are in order. Which none of us do.

The reaction from WHO and UNAIDS is predictably mealy-mouthed. They can’t quite bring themselves to say that the Swiss are right, any more than they can bring themselves to say that the risk of HIV transmission in oral sex for anyone who doesn’t have suppurating mouth wounds is basically zero. The fear is that people might interpret the Swiss statement to mean: if you’re on treatment, you’re not infectious. In other words. they’ll forget about the other IFs. It’s a patronising view: people cannot be trusted to digest the information and make informed choices. As in: “This guy tells me he’s on treatment and he’s good about taking his meds, but then I told him I was on the pill, so…. ”

We’ve been caught out by this many times before. Pretend everything is equally risky, and people will go ahead do dumb things across the board. Let people know exactly what the risks are, and they’ll often choose their dumb things more carefully. If we know that an infected person with good adherence to drugs and excellent medical care can have sex without condoms without endangering their partner, shouldn’t we tell them that? As the Swiss paper says: let the HIV negative partner decide if they want to use extra protection.

It is perhaps worth stressing, though, that all the data they reviewed came from studies in heterosexuals. One exception was a paper from San Fransisco suggesting that HIV incidence was falling among gay men since the initiation of treatment.(Porco st al, 2004) which has sadly since been overtaken by events. In other words, we can’t be quite so sure that a viral load of below 40 copies/ml protects against transmission in anal sex, let alone in injecting, both of which are more efficient than vaginal sex.

There’s something else in the Swiss paper that people haven’t been twittering about, but that I think is really interesting. More here.

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This post was published on 05/02/08 in Ideology and HIV, Pisani's picks, Science.

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  1. Comment by Chris Green, 06/02/08, 05:42:

    This has been the topic of some discussion on the Indonesian language AIDS mail lists. Since this is ‘public’, I feel comfortable to translate some of the comments.

    1. Frika Chia, APN+, in a discordant relationship:

    According to me, this is a very strong statement, that gives me “hope”.

    * Hope for my HIV-positive friends (with great implications for their ‘psychology’)

    * Emphasises that ART is effective as long as adherence is good – so that PLHIV are also responsible to adhere. And of course, the need for perfect drug supply.

    * Providing correct dosage – both patient and doctor are responsible to find out the correct dose, so that our friends who take ARVs can achieve and maintain undetectable viral loads.

    And up to now, what has been voiced by treatment activists that “Treament is Prevention” is very accurate. Increasingly we see that treatment is a part of prevention.

    2. Pandu Riono, epidemiologist.

    This is the evidence which must be considered:

    * Up to now, we have not been successful in eliminating HIV from the body of a person.

    * “Undetectable” HIV status can give the incorrect impression that HIV is no longer there, even no longer infectious. The views of those global-calibre scientists are wrong in interpreting the results of their research and in communicating the results.

    * “Undetectable” status is very temporary. After a period that cannot be determined, it can increase and become detectable.

    * The concept “treatment is prevention” only applies to special situations, for example PMTCT, or also temporary prevention of infection among discordant couples

    * It is important also that a person with HIV has a great chance to infect again and again if he/she does not reduce his/her risk behaviour.

    So, it is clear that this news according to me “dupes” the general public, because of incorrect interpretation of the results of the study.

    3. I have also received a private comment from a doctor who cares for young HIV-positive drug-users in recovery at a government drug rehab hospital near Jakarta. She says:

    “If this is confirmed, adherence and willingness to start ART will increase among the youth (because most of my patients are young and sexually active. It will help in discussion with my patients.”

    4. My personal comments:

    There are many young (often newly married) discordant couples in Indonesia. We frequently hear that the fear that the condom will break impacts greatly on their enjoyment of sex, and even their ability to achieve or maintain an erection, This news will greatly help.

    Further, most of these couples want to have kids. But sperm washing is hardly a feasible option for most where the male partner is positive. So they have to ‘take a risk’ when trying to get pregnant. This news will again allow them to do this with greater comfort, and conceive in joy rather than in fear.

    It is sad that UNAIDS, with as far as I know several PLHIV on its staff, is unable to appreciate these points and has followed such an insensitive line. Once again, this proves that their concern for, and understanding of, infected people is very limited…

    Chris

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